Dear Sir

Response to Prevention of Future Deaths Report

1. Coroner and Case Details Coroner: Rebecca Sutton, Senior Coroner/Assistant Coroner for the coroner area of County Durham and Darlington

Deceased: Susan Elizabeth SAMSON (DOB 10th April 1947)

Date of Death: 7th May 2025

Inquest Conclusion: Narrative conclusion [On 7 May 2025 at her home address in Darlington, the deceased died due to an accidental fall down the stairs. The death was caused by an accident, which was contributed to by an unsafe discharge home from a rehabilitation placement]

Date Prevention of Future Deaths Report Issued: 2nd March 2026

2. Organisation Responding Organisation Name: Darlington Borough Council

Address: Darlington Borough Council, Town Hall, Feethams, Darlington, DL1 5QT

Relevant Service: The Chief Executive

3. Summary of Coroner’s Concerns

CHIEF EXECUTIVE’S OFFICE Town Hall, Darlington DL1 5QT

H.M. Coroners Office P.O. Box 274 Stanley County Durham DH8 1HG

27th April 2026

This document was classified as: OFFICIAL The Prevention of Future Deaths Report identified the following matters of concern:
1. On 18 March 2025 (via an email timed at 16:19) a request was made by staff at Sedgefield Community Hospital to Darlington Borough Council (who were the landlord of the property where the deceased lived) to fit a second banister rail in the deceased’s home.

2. On 10 April 2025 a further request, by an Occupational Therapist working at the Rydal Care Home, was made to Darlington Borough Council to fit a second banister rail in the deceased’s home.

3. An appointment was made to fit the second banister in the deceased’s home on 6 May 2025.

4. For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025. I am concerned by the length of time between the requests for a second banister and the first appointment arranged to fit a second banister. I am concerned that, if similar circumstances arose today, or in the future, a Darlington Borough Council tenant could be exposed to a potentially avoidable risk of death while awaiting the installation of a second banister.

4. Action Taken or Proposed in Response to the Coroner’s Concerns The Council takes the coroner’s concerns extremely seriously. The following actions have been taken and/or are planned to address the concern:

Concern: Delay in responding to requests for minor works/adaptations at council owned property The Council has in place a process for dealing with any works/adaptations to Council owned properties. There is a guide for council tenants. This process is underpinned by a referral form which is to be sent to a manned email inbox for all proposed works.

It is anticipated that works/adaptations such as those required at Susan Samson’s property would usually be completed within 4 weeks. However, wherever possible works/adaptations will be completed within a timescale suitable to all and dependent upon any specific circumstances.

In respect of the observation/concern of the Coroner ‘For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025’. The timeline for the works is as set out in the statement and exhibits of Claire Gardner-Queen dated 26th February 2026. Unfortunately, the Council has not had sight of the email from Sedgefield Community Hospital which was purported to have been sent on 18th March 2025 and we are unable to ascertain whether the email was sent to the correct email address and whether it contained the referral form as required. Email correspondence from the OT from CDDFT indicates that she first made the referral for the second banister on 10th April 2025 and her referral form omitted the date on when Susan Samson would be fit for discharge. The OT had not received a response to that referral, and she contacted an officer of the Council on 28th April 2025 in respect of that referral. The OT advised that there was no one home at the property and gave details as to when Susan Samson was planned on being discharged home, this was planned for 1st May
2025. The works/adaptations were unable to be carried out prior to Susan Samson’s discharge home as there was no one at the property to permit access. Following communication between

This document was classified as: OFFICIAL a Council officer and the OT the works/adaptations which were originally scheduled for 14th May 2025 were brought forward to 6th May 2025 and the OT was advised of this date. The Council can confirm that the works were scheduled to be undertaken on 6th May 2025 and an attempt to install the second banister and grabrails was made on that day, but Susan Samson refused access to her property advising it was not convenient for the banister to be installed. As Susan Samson was a capacitated adult, she was within her rights to refuse access, and the Council was unable to lawfully enter and carry out the works in the absence of her consent.

The Council has reviewed the guide for tenants and are satisfied that there are no changes required to this document.

The referral form and email inbox for receipt of such referral forms remain appropriate, however, the Council intends to raise awareness of the referral process to ensure that all referrals are dealt with in a timely manner and that any queries in relation to the referral form are raised at the earliest opportunity to avoid any delay.

This case will be used as part of that awareness raising to ensure there is appropriate learning.

Random sampling audits will be carried out of the referrals. Should the content of the referrals be of concern then a review of that form will be considered and reissued.

5. How These Actions Will Reduce the Risk of Future Deaths

The action outlined above aims to strengthen and raise awareness of the process for works/adaptations to be completed in respect of council owned properties. This awareness will be raised both internally and with external stakeholders, in particular health colleagues.

It is anticipated that such awareness will improve the level of detail contained within referrals and communications and that such measures will reduce the likelihood of any repeat cases of individuals being discharged home without appropriate work/adaptations being carried out prior to or shortly after a discharge back home, thereby reducing the risk of potentially avoidable deaths in similar circumstances.

6. Ongoing Monitoring and Review Progress against this action will be reviewed by the Council, and any deficiencies will be addressed promptly. Learning from this case will also be shared through briefings within relevant departments [Housing, Adult and Childrens Social Care].

7. Declaration I confirm that the information provided in this response is accurate to the best of my knowledge and that the actions described have been, or will be, implemented as stated. Name: Rose Rouse Job Title: Chief Executive Organisation: Darlington Borough Council Date: 27 April 2026

This document was classified as: OFFICIAL

Should the Council be able to assist any further please do not hesitate to contact myself where I will endeavour to assist wherever possible.

Dear Ms Sutton,

Re: Susan Samson

I am writing in response to Regulation 28 Report to Prevent Future Deaths, which you issued to County Durham & Darlington NHS Foundation Trust on 23 February 2026. We are writing in response to your request for the Trust to take action in relation to concerns as detailed below: The Occupational Therapist involved in the deceased's discharge on 1 May 2025 gave evidence that for someone to be assessed as safe to use the stairs on their own, it was not sufficient for them to have managed to complete a set of stairs without assistance on one occasion; it was necessary for the person to demonstrate that they could consistently complete the stairs without assistance. The Occupational Therapist stated that the two successful attempts in the Care Home seemed to be enough to achieve consistency and indicated that if similar circumstances arose today the patient would still be discharged home at the end of the six-week rehabilitation period. I found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not demonstrated that she was able to consistently complete a flight of stairs without assistance. I am concerned by the evidence that if similar circumstances arose today the patient would still be discharged. I am concerned that there may be occasions in the future that patients will be discharged before they are able to consistently complete a flight of stairs and that, as a result, a death may occur.

The Trust would like to offer its sincere condolences to Ms Samson’s family for their loss. We take very seriously the concerns which you have raised and have provided a response below.

OT stated it was not sufficient to complete set of stairs independently on one occasion, necessary to demonstrate consistency. OT stated that the 2 successful attempts in the care home seemed enough to demonstrate consistency.

It is not always necessary to repeat a stair assessment. The decision should be guided by the clinician’s professional judgement and the patient’s individual risk profile. If a patient has previously completed a stair assessment safely and no additional risk factors are present, repetition is unlikely to be required. However, for individuals with identified risks such as a history of falls, reduced strength or balance, or frailty, repeating the assessment can provide valuable reassurance by demonstrating consistency and safety over time. Ms Samson was assessed in the care home setting on ten occasions and on one occasion in her own home and was assessed as being able to manage the stairs safely. The documentation from the discharge visit states that Ms Samson managed the steps into the house with supervision and managed a sit to stand from the armchair and got up and down the stairs independently using the banister and her stick. It is documented that she was hesitant on the curve at the top of the stairs on way up but had no hesitation on the way down. However, the Trust acknowledges that the clarity around the description of the supervisory role of the therapy staff was unclear and subjective in some of the documentation.

The Coroner found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not demonstrated that she was able to consistently complete a flight of stairs without assistance.

The documentation relating to the stair attempts undertaken prior to discharge from the intermediate care setting does not clearly confirm that the patient completed the stairs without assistance and lacks sufficient objective assessment and clinical analysis. The Trust requires the use of the recognised SOAP note structure (Subjective, Objective, Assessment and Plan) when recording assessments, which was completed, however the use of the term supervision should have been more clearly defined. It is noted that a commode for downstairs use was offered but declined by the Ms Samson. The provision of such equipment could have reduced the risk of falls by limiting the number of required stair transfers each day and minimising the likelihood of the individual rushing to access toilet facilities. However, neither the recommendation for the commode nor the discussion regarding the risks for not having one were documented. In response, the Trust will ensure that SOAP note training is delivered and completed within the next six weeks for all Community Physiotherapy, Occupational Therapy, and Assistant staff, and within four months for all other Physiotherapy and Occupational Therapy staff. In addition, the existing record-keeping audit, which provides assurance regarding compliance with required standards for SOAP documentation will continue to be used to monitor adherence and identify any areas requiring further improvement.

Concern there may be occasions in the future that patients will be discharged before they are able to consistently complete a flight of stairs. Ms Samson was identified as being at an increased risk of falls, with several contributing factors including frailty and a documented history of previous falls. However, there is insufficient documentation regarding her understanding of these risks and her expressed preferences around discharge. Although elements of falls risk and mitigation are recorded, this information is not consolidated within a single, clearly identifiable document in the current patient record. The incorporation of a validated home-hazard assessment tool, such as the HomeFAST (Home Falls Accident Screening Tool), would strengthen the assessment process. This tool specifically evaluates environmental risks, including stairways and steps and prompts the clinician to develop a structured action plan, thereby supporting more comprehensive documentation and risk management. In response to this incident, the Trust will undertake a review of the current documentation and the electronic record template to identify any required amendment and include a validated home hazard assessment tool.

Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.